Safety of care
Videoconferencing consultation: When is it the right choice?
Originally published October 2015
According to the 2014 National Physician Survey, 25% of physicians are using telehealth or telemedicine technologies in their practice. Of those, 30% are using it for consultations, 28.7% for following up with patients, 18.6% for treatment, and 23.6% for ongoing management.1
Videoconferencing is one of many telemedicine tools currently available. It can be an optimal method for providing care to patients at a distance. Despite its efficiency and convenience, physicians must still exercise professional judgment to determine when it is appropriate to provide care virtually and when an in-person consultation with their patient is necessary or desirable.
Electronic methods of communicating and interacting with patients and colleagues, including videoconferencing, are being used to deliver healthcare in urban centres as wells as remote rural regions of Canada. Noteworthy telemedicine networks include the Yukon Telehealth Network, the Nova Scotia Telehealth Network, Telehealth Saskatchewan, Alberta Telehealth, Réseau Universitaire Intégré de Santé (RUIS) in Québec, and the Ontario Telehealth Network, the latter being one of the largest telemedicine networks in the world. Patients benefit from electronic communication and interaction in many areas, including mental healthcare, occupational and speech therapy, discharge planning, chronic disease management, homecare, addictions counselling, follow-up visits, and some consultations.
Physicians who use videoconferencing as a method to provide care in their practice should consider the unique circumstances of each patient, including his or her clinical needs, and decide whether or not videoconferencing is appropriate in those circumstances.
Physicians should also be familiar with their medical regulatory authorities’ (Colleges’) position on the use of videoconferencing consultations. Generally, Colleges recommend physicians use their professional judgment to determine whether a videoconference consultation is appropriate in a particular circumstance, and whether it will enable physicians to meet the standard of care. For example, the College of Physicians and Surgeons of British Columbia advises physicians to "…explain the appropriateness and limitations of technology-based patient consultation and consider whether a physical examination is necessary…"2
Appropriate prescribing of medication
As with all prescribing, the Colleges expect physicians in a videoconference consultation to follow professional guidelines and policies when considering a prescription for a patient, such as taking an appropriate patient history, and being aware of the patient’s current medications and allergies. These activities are particularly important when physicians are prescribing medications to new patients whom they have never personally examined or patients with a history of substance abuse. Physicians should also exercise caution when prescribing opioids and other controlled substances, and should familiarize themselves with their College’s policy on prescribing these medications.
In one example from a closed CMPA case, a physician provided telemedicine care to a new patient and omitted to take an adequate patient history before prescribing alprazolam, a potentially addictive drug. The prescription was faxed to a pharmacist, who subsequently filed a College complaint against the physician for improperly prescribing a medication with the potential for addiction and abuse, and for not checking the patient’s medical profile. The College was critical of the physician’s decision to prescribe the alprazolam to a new patient seen in a telemedicine setting in the absence of an adequate patient history and profile. The College cautioned the physician. It also recommended enrollment in a prescribers’ course and a review of its telehealth services standards.
Limitations of videoconferencing
When considering videoconferencing, physicians should also consider the privacy offered by the physical locations. Whether providing care in-person or electronically, physicians must protect patients’ personal health information. Patient confidentiality can be compromised if the physician’s and patient’s locations do not offer adequate privacy. Both individuals should be located in a private setting where the patient can comfortably share confidential information and where the physician can provide advice and assess the patient.
Technical limitations, such as low bandwidth, poor screen resolution, or unsecure networks and portals can also affect the quality of care physicians can provide via videoconferencing and compromise patients’ privacy. Inexpensive and readily-available hardware and software may facilitate videoconferencing, but lead to greater technical limitations. Physicians should avoid using videoconferencing if the standard of care or the physicians’ obligation to protect patient privacy and confidentiality cannot be met.
In two other CMPA videoconferencing cases resulting in a negative outcome, plastic surgeons used Skype to examine patients who had received Botox and filler injections. The physicians never saw the patients in person, though the patients had previously been examined by a nurse to whom the physicians delegated the assessment and treatment. The Skype examination took place after the treatment when the patients complained of poor results, complications, and inadequate follow up with the nurse. The patients later complained to the College. In both these particular cases, the College determined that a skin assessment could not be done adequately via videoconferencing and that Skype did not meet the security standards for telemedicine. The plastic surgeons were also cautioned about appropriate delegation and supervision.
Before engaging in videoconferencing consultations with a patient in a different province or territory, physicians should consider whether they have met the licensing requirements applicable to the consultation. Telemedicine licensing requirements vary for each province and territory. Some physicians practising telemedicine might need to be licensed in both the jurisdiction in which they are located and the jurisdiction where the patient is located. Some Canadian jurisdictions may also require special registration, or they may place conditions on the provision of such services, or both. Physicians should therefore be familiar with the requirements of each province and territory in which they practise and their patients reside.
Consent for electronic communications
Physicians should manage patients’ expectations with respect to videoconferencing by discussing the limitations and risks involved in such exchanges. They should separately document the patient’s informed consent, specifically noting patient consent to using videoconferencing to communicate potentially sensitive personal health information. Physicians remain responsible for deciding what constitutes sensitive information and how to communicate it. Physicians should also consider asking the patient to sign a consent form like the CMPA’s template "Consent to use electronic communications [PDF, DOC]".3
Risk management considerations
When providing care through electronic means, including via videoconferencing, physicians should remember that their professional obligations remain unchanged. They should consider the following points to manage risk:
- Be aware of and follow policies and guidelines for telemedicine or eCommunication set by the College and privacy regulator in your jurisdiction, including those on encryption of sensitive information.
- If a videoconferencing consultation will occur across provincial or territorial boundaries, ensure that you have fulfilled the licensing requirements applicable to the consultation.
- Ensure reasonable information security safeguards are in place to reduce the risk of privacy breaches.
- Before an assessment begins, patients must consent to the use of videoconferencing as a method of electronic communication with the physician. You may wish to refer to the CMPA’s "Consent to use electronic communications [PDF, DOC]" form to guide the informed consent discussion. Document both the consent discussion and any written agreement in the patient’s medical record.
- Ensure that the nature of the consult and the patient’s condition are suitable for videoconferencing.
- Whether using telemedicine or performing an in-person consultation, conduct an appropriate and complete patient assessment; document the encounter including the specifics of the electronic aspects; and identify the most responsible physician, if multiple providers are involved.
- When appropriate, have a backup plan in the event of a technical failure. For example, identify an appropriately trained and skilled on-site healthcare provider who can provide assistance, if needed.
- Be aware of billing requirements in your jurisdiction.
Contact the CMPA
CMPA members are encouraged to contact the CMPA and speak with a medical officer to discuss individual concerns or questions regarding videoconferencing and telemedicine.
- "Telemedicine — Opportunities, challenges, and obligations"
- "Consent to use electronic communications [PDF, DOC]"
- National Physician Survey, “National Physician Survey, 2014. National Results by Province.” Retrieved on August 12, 2015 from: http://nationalphysiciansurvey.ca/wp-content/uploads/2014/10/2014-ByProvince-TelehealthTelemedicine-EN.pdf
- College of Physicians and Surgeons of British Columbia, “Professional Standards and Guidelines- Telemedicine”, March 2015. Retrieved on May 14, 2015 from: https://www.cpsbc.ca/files/pdf/PSG-Telemedicine.pdf
- Canadian Medical Protective Association, Consent to use electronic communications form, 2015. Accessed August 26, 2015 from: https://www.cmpa-acpm.ca/-/new-form-consent-to-use-electronic-communications